Project Description

Orthotics & Orthopaedics

What you need to know

WHAT ARE ORTHOTICS & ORTHOPAEDIC SHOES?

Both orthopaedic shoes and orthotics are prescribed to treat a medical condition(s). Orthopaedic shoes (or boots) can either be purchased “off-the-shelf” with modifications and/or adjustments for the specific patient, or they can be custom-made. Orthotics are custom inserts created to be worn inside a shoe. The main difference is orthopaedic shoes are a complete piece of footwear, and orthotics are an insert.

ELIGIBILITY

In order to be eligible for coverage under your benefits plan, your orthopaedic shoes and/or orthotics must be prescribed and dispensed by eligible service providers. To ensure coverage, it’s recommended that a pre-authorization be submitted to your GroupHEALTH client services representative.

COVERAGE: OFF THE SHELF OR CUSTOM?

Both orthopaedic shoes and orthotics are prescribed to treat a medical condition(s). Orthopaedic shoes (or boots) can either be purchased “off-the-shelf” with modifications and/or adjustments for the specific patient, or they can be custom-made. Orthotics are custom inserts created to be worn inside a shoe. The main difference is orthopaedic shoes are a complete piece of footwear, and orthotics are an insert.

Industry standards for coverage of “off-the-shelf” orthopaedic shoes frequently change, but typically, they must meet the following criteria:

  • Broad sole (through the heel, shank and forefoot)
  • Adjustable closures (to secure foot position)
  • High, broad toe shape
  • Extra wide
  • Removable sock liner
  • Easily modifiable upper & sole that is breathable, mouldable & durable
  • Smooth protective lining
  • Heel stability via firm or extended heel counter
In order for claims to be paid or estimates to be assessed, the following requirements must be met:

  • Prescription from an eligible prescribing Service Provider (Physician, Podiatrist or Chiropodist)
  • Diagnosis of the condition and symptoms
  • Gait analysis/biomechanical exam
  • Description of how the orthotic or custom-made shoe was constructed and the raw materials used OR a description of the modifications made to the shoes INCLUDING a breakdown of the costs and the brand name, model name and model number of the shoe
  • Name and license number of the dispenser
  • Shoes and orthotics must be dispensed by a licensed, eligible Service Provider other than the prescriber or if dispensed by the same Service Provider, the orthotics or shoes must be manufactured or modified in an off-site facility. Eligible dispensing service providers include:
    • Orthotist CO or CPO (c)
    • Pedorthist C Ped (c) or C Ped (MC)
    • Podiatrist (DPM)
    • Chiropodist (D CH or D Pd M)
    • Orthésistes du Pieds (member of CCCOP)